Provider Demographics
NPI:1316044977
Name:LAKE, HALEEMAH (LCSW)
Entity Type:Individual
Prefix:
First Name:HALEEMAH
Middle Name:
Last Name:LAKE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 526
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-0526
Mailing Address - Country:US
Mailing Address - Phone:860-303-0336
Mailing Address - Fax:
Practice Address - Street 1:567 VAUXHALL STREET EXT STE 316
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:CT
Practice Address - Zip Code:06385-4341
Practice Address - Country:US
Practice Address - Phone:860-303-0336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT 0048411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical